Walnut Hill Dialysis Center

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 50181 Based on direct observation, the dialysis facility failed to provide and monitor a sanitary environment to minimize the transmission of infectious agents within the dialysis treatment area. These findings have the potential to increase the risk of infection to all patients receiving treatment at the facility by increasing the potential of cross-contamination between patients. Findings: During a tour of the facility’s in-center treatment area on 08/20/2025 at 10:20AM the following was observed: At station #17, patient #38, with a central venous catheter, had a portable fan in use during treatment. In an interview, staff #1 (Facility Administrator), confirmed that portable fans were not allowed during dialysis treatments in the in-center treatment area.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 50181 Based on observation and interview, it was determined that the facility staff failed to appropriately label prepared medications with the time and initials of the person who prepared the medication. During a tour of the facility’s in-center treatment area on 08/19/2025 with the Facility Administrator (Staff # 1), the surveyor observed medications prepared by the staff without the time and initials of the person who prepared the medication. Staff #1 confirmed and acknowledged the above findings during the tour of the in-center treatment area on 08/19/2025.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 50181 Based on direct observation and staff interview, the staff failed to ensure their hands were washed or sanitized after each glove change and between patients. These findings have the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility by increasing the potential of cross-contamination between patients. Findings:On 08/20/2025, during treatment observations on the floor the following was observed:At approximately 10:05 AM, at station #10, staff #4 left the station with gloves donned and discarded trash in the trash can and then went to station #9 without removing gloves and sanitizing hands to setting up the dialysis machine. At approximately 10:11 AM, staff #5 was at station #16 with donned gloves preparing to remove needles post treatment. Then, without removing gloves and sanitizing hands, staff #5 went to the clean supply cart and obtained a glove from the cart and then went back to station #16 to proceed removing the patient’s needles post treatment. On 08/20/2025, staff #1 (Facility Administrator) confirmed that staff were required to remove gloves and sanitize hands prior to obtaining clean supplies from the supply cart and after discarding trash.”